Residency Rules: Shift Limits Dissed

Program directors who manage interns and residents approve of most of the workload requirements implemented 18 months ago, except for duty-hour restrictions, a survey found.

The 549 respondents overwhelmingly approved of 1 day off each week for residents (87.8%), direct supervision of first postgraduate year residents (76.7%), and the 80-hour workweek (73.4%), according to Brian C. Drolet, MD, of Rhode Island Hospital in Providence, and colleagues. Many respondents also liked night-shift frequency of fewer than 7 consecutive days (70.5%), and 8 hours' relief between shifts (70.3%).

However, a clear majority (71.6%) of respondents did not approve of the 16-hour shift limit for interns, the investigators reported in a Perspective article in the Feb. 21 issue of the New England Journal of Medicine. Less than half (42.7%) said their residents complied with the requirements, and most program directors (73.8%) also reported an increase in their workloads.

Program directors have consistently opposed limiting residents to 16-hour shifts even before the Common Program Requirements were implemented by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, the authors noted.

At least one study has previously found that the new rules were not necessarily helping interns to limit their fatigue. To find out more about how program directors were feeling now that the rules have been implemented, researchers conducted an email survey of residency programs in general surgery, internal medicine, and pediatrics that were accredited by the ACGME. The survey had a response rate of 75%.

The survey also found:

Nearly half of respondents (48.2%) said that quality of patient care is unchanged (and 45.8% said it was worse).

More than half (57%) said patient safety was unchanged (or worse, 36.2%).

Nearly two-thirds (64.8%) said resident education is worse.

About three-fourths (73.2%) said resident preparation for more senior roles is worse.

Quality of life for residents was the only improvement seen by about half of program directors (49.5%) polled, the researchers said.

Colleen Christmas, MD, associate professor of medicine and residency program director at Johns Hopkins Bayview Medical Center, said she was not surprised by the findings and believes the requirements need more time and buy-in from senior program directors. Many program directors are frustrated, she said in an interview, because the new requirements do not reflect their experience as an intern decades ago.

Traditionally, interns have been "exhausted and unsupervised," observed Christmas. "Maybe that's not the best way to learn."

At Hopkins Bayview, she said, "we've changed our system so people are working more shift work, which is what real doctors actually do. Not too many docs in the real world work 30-hour shifts."

She said that at her medical center "our handoffs are safe, our residents are not as exhausted, our environment is based more on learning and less on seeing as many patients as you possibly can and not getting to study those patients more carefully." She and colleagues are collecting data looking at burnout, readmission rates, medical errors, and similar outcomes to measure the impact of the changes.

The 32-question survey included six demographic questions and one open response. The survey asked program directors to rate the 2011 requirements and their impact on training and patient care, and how compliant they were with resident duty hours.

The majority of respondents were male (69%), and they were more likely than female program directors polled to disapprove of the regulations (28.2% versus 18.5%, P<0.01). Greater disapproval was lodged by program directors at academic centers compared with community-based centers, and by program directors of greater seniority.

The respondents were also mostly between 41 and 60 years old (69.4%) and worked at teaching medical centers (60.7%); many had been program directors for 5 years or less (42.6%). Pediatric program directors produced the highest response rate (83.4%). Internal medicine (75.7%) and surgery (65.3%) followed.

Among specialists, surgeons were 2.9 times as likely to deem patient safety as worse (P<0.01) under the new rules. Pediatricians were 6.5 times as likely to report a lesser quality of life for residents (P<0.01).

"Although the ACGME remains committed to self-regulation of residency working conditions, our findings highlight the problem of applying a common standard to more than 100,000 resident physicians in the U.S.," the researchers stated in the findings.

They suggested that "residency review committees" devise rules to see residents along their careers while ensuring patient care.

"We also think it would be helpful to survey residents and program directors regularly to assess the effects of ACGME regulations on educational experience, achievement of milestones, competency for independent practice at graduation, life of trainees, and effects on patient care," they stated in the findings. "More detailed study of the effects of fatigue and work hours on patient outcomes, 'near misses,' and medical errors is also warranted."

Unlike residents, who were polled by Drolet and colleagues in 2012, 48% of program directors supported restricting senior residents' shifts to 24 hours. In Drolet's poll of residents, only 22% favored the 2011 regulations.

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